Coding form dominance in color, shading, and achromatic color responses (Form Dominant, Form Secondary, Formless) has traditionally been an important aspect of Rorschach assessment of ego involvement in the regulation of emotions. The more Form involvement, the more one is accessing cognition to structure and modulate one's experience of emotions. For psychometric and pragmatic reasons, contemporary Rorschach systems have eliminated or curtailed coding form dominance of shading and achromatic color (FDSHAC). Positing that this sacrifices interpretive nuance, we have recently attempted to demonstrate that with supplemental guidelines, FDSHAC can be coded reliably and accurately. We found, however, that the weak link is coding Form Secondary. Thus, using the same data set coded by four experienced Rorschachers, we attempted to mitigate this by evaluating two alternate versions of FDSHAC: One collapses Form Secondary with Form Dominant into a category called "Form Integrated"; the other, Form Secondary with Formless into "Non-Form Dominant." Applying more conservative kappa statistics, which credit only exact matches among raters, the Form Integrated version generally showed stronger interrater reliabilities and scoring accuracies and thus is a promising compromise for assessors wishing to retain some nuance in interpreting ego involvement in the regulation of dysphoria and anxiety. Intraclass correlation coefficients, which credit close-but-inexact coding among raters, revealed little difference. Clinical and research implications as well as limitations are discussed.

Abstract: Coding form dominance in color, shading, and achromatic color responses (Form Dominant, Form Secondary, Formless) has traditionally been an important aspect of Rorschach assessment of ego involvement in the regulation of emotions. The more Form involvement, the more one is accessing cognition to structure and modulate one’s experience of emotions. For psychometric and pragmatic reasons, contemporary Rorschach systems have eliminated or curtailed coding form dominance of shading and achromatic color (FDSHAC). Positing that this sacrifices interpretive nuance, we have recently attempted to demonstrate that with supplemental guidelines, FDSHAC can be coded reliably and accurately. We found, however, that the weak link is coding Form Secondary. Thus, using the same data set coded by four experienced Rorschachers, we attempted to mitigate this by evaluating two alternate versions of FDSHAC: One collapses Form Secondary with Form Dominant into a category called “Form Integrated”; the other, Form Secondary with Formless into “Non-Form Dominant.” Applying more conservative kappa statistics, which credit only exact matches among raters, the Form Integrated version generally showed stronger interrater reliabilities and scoring accuracies and thus is a promising compromise for assessors wishing to retain some nuance in interpreting ego involvement in the regulation of dysphoria and anxiety. Intraclass correlation coefficients, which credit close-but-inexact coding among raters, revealed little difference. Clinical and research implications as well as limitations are discussed.

As described in the last chapter, psychological assessment methods are used in clinical settings to identify unique aspects of an individual's experience and functioning for diagnostic clarification and treatment planning. In contrast, research-based methods are intended to assess symptom-related constructs in a broader population of patients and nonpatients. Research-based scales can be grouped into categories that distinguish the instruments' purpose, intended use, nature, and scope. Some instruments were developed for research purposes and intended for scientific investigations. Others were designed to be used in a clinical setting.

While performing a religious ritual in a local church, Ms. B., a 40-year-old woman, reports hearing voices of spirits and goes through a trance-like experience. Shortly afterward, she passes out and is taken to a medical emergency room.

How does psychosis begin, and how does it progress and resolve? Are there typical patterns of onset, predictable phases, and courses? To address these questions, we review the nature of psychosis onset, phases of symptom development, and typical courses of psychotic conditions. Charting the course of psychosis leads to a discussion about outcome and prognosis.

In many forensic psychological evaluations, it is vital to assess accurately whether a person has a psychotic disorder. In some cases, such as insanity evaluation, establishing the presence of a psychotic disorder is essential and directly related to psycho-legal questions (Goldstein et al., 2013). In other forensic examinations, like sentencing mitigation, establishing the presence, degree, or severity of psychosis can be an indirect but critical mitigating factor (Khadivi, 2017).

Understanding the diagnostic classification of psychotic disorders requires a review of historical changes in psychiatric nosological systems. In reviewing these changes, there are multiple factors that we need to consider. These include: Tracing the conceptual changes in how psychosis has been understood over time. Noting how affective symptoms have been understood in the diagnosis of psychotic conditions. Being aware of key empirical studies in differential diagnosis. Understanding the impact of new psychotropic medications on diagnostic practice. Finally, it is essential to realize how, with the advent of the DSM-III, the shift in emphasis to interrater reliability began to shape current diagnostic practices for all conditions, including psychoses.

We reevaluated HiTOP's existing factor analytic evidence-base for a Psychosis (P) superspectrum as encompassing two psychosis-relevant subfactors ("spectra")-Thought Disorder (TD) and Detachment (D). We found that their data did not support P as a superspectrum with TD and D subfactors. Instead, TD contained both positive and negative symptoms of psychosis and emerged at the subfactor level. D did not target negative symptoms but, largely, disorders unrelated to psychosis and should not be placed under P. Determining if P is truly a superspectrum with psychosis TD and D subfactors will require factor analyses whose items are symptom-based and span the full range of psychopathology. Secondly, HiTOP authors state that TD and D provide a "nearly 2-fold" improvement in reliability over schizophrenia diagnoses but, after aligning the comparative study methodologies, this 2-fold improvement disappears. Finally, HiTOP's use of the term thought disorder is inconsistent with the ICD-11 and psychosis literature, in which it refers to formal thought disorder. We recommend that HiTOP (a) refer to P as a subfactor with positive and negative symptoms of psychosis until research indicates otherwise, (b) regularly rely on formal systematic reviews, (c) use appropriate reliability comparisons, (d) deconflate D with negative symptoms, and (e) rename TD.

There is a consensus in the literature that the presence of psychotic symptoms increases the risk of suicide (APA, 2003; Jacobs & Brewer, 2006). The literature on suicide and psychosis has focused chiefly on schizophrenia, schizoaffective disorder, and first-episode psychosis, with less information on suicide risk in other psychotic disorders (Hor & Taylor, 2010).

Each core symptom briefly introduced in Chapter 1 has a large body of supporting research. Beyond cataloging them as diagnostic criteria, each can be unpacked by reviewing seminal research and contemporary theories to understand the conceptual underpinnings and diagnostic implications of these core symptoms of psychosis.

When assessing psychosis, clinicians confront an array of descriptive terms, which may clarify and sometimes confuse essential concepts. For example, underlying psychosis, psychotic continuum, psychotic syndromes, psychotic spectrum, subthreshold psychosis, psychotic proneness, psychotic dimensions, psychotic states, and psychotic experiences may be used interchangeably or to represent different aspects of psychotic phenomena. Seiler et al. (2020) reviewed seven psychosis-related terms representing points along the continuum of psychosis and noted confusion and inconsistencies in how the terms are used. Defining and organizing terminological diversity will help clinicians understand conceptual similarities and distinctions and sharpen diagnostic decision-making.

Testing also affords a good view of psychological functioning because it requires patients to "display" a variety of ego functions, not merely to "describe" ego functioning as they might do during interviews (Miller, 1987, p. 507). Readers are directed to a comprehensive review of the psychological assessment of disordered thinking and perception, which is a key component of assessing psychosis (Weiner & Kleiger, 2021).

The connection between psychoses and violence has produced conflicting findings. Earlier studies of civil psychiatric patients discharged from emergency room or inpatient services indicated that the link between psychosis and violence was negligible (Appelbaum et al., 2000; Monahan et al., 2001; Steadman et al., 1998). Also, Bonta (Bonta et al., 1998), using a meta-analysis, reported either a negative or small association between psychosis and violence in mentally disordered offenders.

A clinical interview is the primary and most essential assessment method for evaluating psychotic disorders (Shea, 2016). It offers the most flexibility in exploring symptoms and allows the clinician to observe signs of psychosis, such as thought disorder, negative symptoms, and disorganized behavior. In this chapter, we will discuss what we consider to be the most effective clinical interview techniques and questions in assessing psychosis. Consistent with the dimensional perspective of psychosis, we will evaluate eight symptom domains proposed by Barch et al. (2013). These include: Hallucinations. Delusions. Disorganized speech. Bizarre and abnormal psychomotor behavior. Negative symptoms. Cognitive impairment. Depression. Mania.

Psychosis profoundly impacts the level of insight and degree of trust and, in some cases, impairs the patient's ability to communicate coherently or rationally. As a result, the differential diagnosis of psychotic disorders is a challenging task (Fuji & Ahmed, 2007; Skodol, 1989). In this chapter, we place advances in the most recent version of the Diagnostic Statistical Manual DSM-5-TR (APA, 2022) at the center of our review. First, we examine the conceptual issues related to the differential diagnosis of psychosis. Then, we introduce a modified approach for the differential diagnosis of a psychotic disorder. Finally, we discuss differential diagnosis by examining the core diagnostic features of relevant disorders and the challenges one encounters in arriving at accurate diagnoses in clinical practice.

Nine-year-old Jessie's mother brought him in for an evaluation because he had been hearing voices for several years. The taunting quality of these voices increased to the point that they began instructing him to hit other children. After he succumbed to these commands and struck a classmate, his symptoms reached a threshold requiring professional attention. A history of schizophrenia in a second-degree family member worried his pediatrician, who referred Jessie for a psychological evaluation. Jessie's response to items from a Scale to Measure Unusual Beliefs and Experiences Among Children and Adolescents, CUBESCALE (Child Unusual Belief Scale; Andersen, 2006; Viglione et al., 1994; Viglione & Senecal, 2014), a semi-structured instrument for assessing unusual beliefs in children, illustrated the bizarre nature of both his thoughts and how he communicated his ideas. The CUBESCALE, discussed later in this chapter, consists of 40 statements to which the child responds either "True" or "False." The interviewer follows up affirmative responses with additional clarifying questions. To the statement, "Sometimes, I don't have any insides," Jessie responded, "True," and explained his answer in the following way, I feel weightless, or if I am hungry, I feel my stomach disappear and everything having to do with the stomach. Everything that is linked or shares the same space… . Sometimes I feel weightless, and my bones are just missing, and I collapse. So if you think about sad things, normally you just turn sad.

Although emphasis on psychodynamic thinking has waned in assessment training, the ascendant Rorschach Performance Assessment System (R-PAS; Meyer et al., 2011) has reintegrated psychoanalytic concepts into empirical Rorschach assessment: R-PAS adds scores involving object relations, implicit dependency, aggressive ideation, and ego impairment. R-PAS has, however, excluded the psychodynamic framework for assessing ego involvement in the regulation of anxiety/dysphoria by eliminating the coding of Form Dominance in Shading and Achromatic Color (FDSHAC) that has been part of the Comprehensive System (Exner, 2003). This decision was based in part on concerns about efficiently and reliably coding distinctions among Form Dominant, Form Secondary, and Formless levels of FDSHAC. To establish that such distinctions can be coded reliably, we applied supplemental guidelines (Viglione, 2010) to evaluate reliability among four experienced assessors who coded determinants for 155 Rorschach responses, 115 of which required FDSHAC determination. Applying Gwet's AC2 ' s to ordinal scales, interrater reliabilities were good to excellent. Reliabilities were strongest for Form Dominance in Texture and Achromatic Color, modestly so for Form Dominance in Diffuse Shading, and problematic for Form Dominance of Vista. Among levels of Form involvement across FDSHAC variables, raters had the most difficulty distinguishing Form Secondary. We discuss considerations for clinical coding, psychodynamic configurational analyses for interpretation, and construct validation research.